Medical Approval officer

Job Purpose

As a Medical Approval Officer, you will play a pivotal role in ensuring the seamless execution of SAICO’s medical approval operations. Your primary responsibility will be to oversee and coordinate the clinical evaluation of treatment plans and return-to-work strategies, aligning them with established medical standards and regulatory protocols. This position demands meticulous attention to detail, strong clinical judgment, and the ability to balance cost-effectiveness with high-quality patient care.

Key Responsibilities

• Clinical Evaluation and Approval Processing: Conduct thorough and ongoing clinical assessments of treatment plans and return-to-work proposals to ensure compliance with medical standards and coverage guidelines. Process and manage all medical approval transactions efficiently during your assigned shift, adhering to approved policies and regulatory requirements.
• Compliance with Turnaround Time (TAT): Ensure all medical approval requests are processed within the specified turnaround times:
  • Out-Patient (VVIP, VIP, A Classes): 0–10 minutes
  • Out-Patient (B, C, D Classes): 0–15 minutes
  • In-Patient (All Classes): Less than 60 minutes
• Policy Adherence and Decision-Making: Review and respond to approval requests in accordance with policy coverage. Request additional medical information when necessary to support informed and accurate decision-making.
• Collaboration with Healthcare Providers: Coordinate with medical providers to ensure the delivery of appropriate care. Recommend cost-effective treatment alternatives when medically justified to optimize resource utilization without compromising patient outcomes.
• Communication and Documentation: Maintain clear and effective communication with healthcare providers not covered by field doctors to ensure continuity and quality of care. Obtain and review medical records and supporting documentation from providers during initial contact, with appropriate follow-up through written correspondence.
• Case Coordination and Fraud Prevention: Liaise with medical providers and injured parties to coordinate timely and appropriate medical care. Identify and refer suspicious or high-risk cases to the Fraud, Waste, and Abuse (FWA) team in accordance with internal guidelines to mitigate potential risks.
• Documentation and Reporting: Ensure accurate and comprehensive documentation of all case activities, including contacts, decisions, and outcomes, within the system. Submit billing or activity reports as required by organizational standards and regulatory obligations.
• Continuous Professional Development: Actively participate in Learning & Development initiatives and complete a minimum of 25 training hours annually to maintain and enhance clinical, operational, and insurance-related knowledge.

Qualifications & Experience

To excel in this role, you must meet the following qualifications and experience requirements:

• Minimum Qualifications:
  • Bachelor’s degree in Medicine (MBBS).
  • Valid license from the Saudi Commission for Health Specialties (SCFHS).
• Minimum Related Experience:
  • 1 to 3 years of relevant experience in a clinical or medical approval setting.